Nursing Home Staff Vaccine Rates Promising Ahead of CMS Deadline, But Boosters May Be a ‘Step Too Far’

As the Centers for Medicare & Medicaid Services (CMS) vaccine mandate deadline looms this week, nursing homes across the country have stepped up to get their staff vaccinated in time – while still lagging on booster numbers.

Nearly 85% of nursing home staff per facility are vaccinated, according to CMS data, and 87.3% of residents are vaccinated per facility. Boosted staff rates are more sobering at 40.5%, whereas residents per facility with their booster is 73.4%.

After the U.S. Supreme Court ruling in January, which upheld the CMS mandate against federal injunctions out of Missouri and Louisiana, health care workers in 24 states had until Feb. 14 to get their first shot and March 15 to be fully vaccinated.


The high court allowed the CMS vaccine mandate to stand while tossing another mandate order issued by the Occupational Safety and Health Administration (OSHA).

The new deadlines applied to Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Utah, West Virginia and Wyoming.

Texas was the last state to have its injunction stayed – CMS issued a memo on Jan. 20 requiring nursing homes in the state to get staff their first shot by Feb. 21 and the second on March 21.


States that didn’t fall under the injunctions were considered non-compliant with the mandate after Jan. 28, but were allowed extra time if they met certain compliance thresholds.

Washington, Oregon, Nevada, California, Colorado, New Mexico, Minnesota, Wisconsin, Illinois, Michigan, Tennessee, Florida, Maine, Vermont, New York, Pennsylvania, Massachusetts, Rhode Island, Connecticut, New Jersey, Delaware, Maryland, District of Columbia, Virginia and North Carolina were among the states whose deadline was Feb. 28 for both doses.

Ahead but still behind

Since the mandate was announced in August, some states like Ohio have made considerable progress, jumping 20% in vaccination rates within a year but still at the end of the pack.

Ohio has one of the lowest staff vaccination rates at 73.19%, only beating Missouri at 72.81%. The state is more in the middle of the pack ahead of 14 states with the booster included, according to CMS data.

Ohio Health Care Association (OHCA) Executive Director Pete Van Runkle said one can more or less take the difference between a state’s vaccinated and unvaccinated rate percentages to figure out who was granted exemptions.

“We’ve got a couple of people who are still figuring out what they’re going to do, but it’s not a significant number,” Van Runkle said. OHCA hasn’t heard from a lot of operators that still have unvaccinated people on their roster without an exemption.

The number of workers that resigned due to the mandate was “not anywhere near the numbers” that operators were concerned about when it was first announced, Van Runkle said. A big part of that came down to the religious exemptions, he said.

“That went a long way toward taking care of that problem,” Van Runkle said of the exemptions. “We haven’t had droves of people leaving.”

Ohio was below 60% in its staff vaccination rate when CMS announced its mandate in August – members at that time were expecting the remaining 40% of unvaccinated workers to leave the industry.

“That just didn’t turn out to be true again, because they allowed for exemptions … there hasn’t been any data collected on it, but I would say it’s less than 5%, probably a lot less than 5%, maybe 1%, that have left because of the mandate,” Van Runkle said. “Had there not been a religious exemption, I think we would have seen quite a few more people leave.”

OHCA members have had surveyors in their buildings ahead of the mandate deadline but there have been no citations in the state related to the mandate, added Van Runkle.

“Members seem to be in pretty good shape, as far as compliance is concerned from what I hear from them,” he said.

Larger operators like Norcross, Ga.-based PruittHealth devoted $23.4 million to incentivizing COVID-19 vaccination and retaining its workforce since the start of the pandemic, the company said in its 2021 COVID-19 report.

Pruitt offered cash raffles for vaccinated staff and bonuses between $250 and $1500 per vaccinated worker as part of its incentives. Nearly 100% of Pruitt’s workers are fully vaccinated as of report publication in early March.

Adding the booster

Van Runkle said the boosters have been even more challenging for operators in the state, with the more contagious omicron variant causing breakthrough infections and testing worker trust in the vaccine.

Just imagine finally convincing staff to get their first doses, he said, only to have them question its efficacy when fellow vaccinated and boosted workers get sick with the variant.

“A lot of folks look at that and say, well, what’s the point? [With omicron] people didn’t get that sick, particularly if they at least had the initial series of shots,” van Runkle said. “When you see that firsthand, which lots of folks in long-term care did, it tended to make them skeptical of the need for the booster.”

That’s despite information released by the Centers for Disease Control and Prevention (CDC) stating individuals are better protected against severe illness, hospitalization and death if they get a booster shot five months after the second dose, or two months after the one-shot Johnson & Johnson vaccine.

As of March 10, CMS required staff to get at least once per week testing if they are not “up-to-date,” meaning they have received all recommended COVID-19 vaccines including booster doses when eligible.

If staff are not boosted and the level of community transmission is between moderate and high, CMS said they must be tested between once to twice a week.

For Ohio, that means the number of staff required to be tested weekly, or, depending on community spread, twice a week, has increased from 26.81% to 67.14%.

“It’s a big change that way,” Van Runkle noted. “We’re not having to test as much because of the reduced number of cases, Ohio is mostly yellow now on the CDC map so we can bring down the frequency of testing but we’re going to have to test a lot more broadly.”

Other states like Illinois as of February opted to mandate the booster in order for facilities to be considered fully vaccinated ahead of testing changes made by CMS.

“What I’m hearing from a lot of my providers is, we had folks who were fine getting the vaccine, thought it was the right thing to do, did it. But now the boosters are just a step too far,” said Matt Hartman, executive director of the Illinois Health Care Association (IHCA). “We just can’t afford to lose staff with it.”

Illinois currently has 86.68% of its nursing home staff vaccinated; only 40.92% of workers are what CMS considers “up-to-date.” The state was not involved in any of the previously mentioned federal court injunctions.

Greenwich, Conn. facility The Nathaniel Witherell increased booster doses for staff from about 20% to 90% in a month, Executive Director John Mastronardi told Skilled Nursing News. Like Illinois, Connecticut mandated the booster shot along with initial doses to be considered fully vaccinated.

“Our infection preventionist, our director of nursing (DON), they really did … an incredible job of being out there every single day, saying this is urgent, you have to do it,” said Mastronardi. “We’re not finished but it’s pretty amazing.”

The rural divide

Vaccination challenges, at least in Ohio, have been a rural issue, Van Runkle said. The vaccination “divide” leaves some facilities in rural southeast Ohio with only 30% of its staff vaccinated, while urban operators have reached 80% to 90%.

“We have a lot of areas in the state where people are just not there, they’re against vaccinations, they’re just not going to have them,” Van Runkle said. “That carries over to the people that work in long-term care; they’re members of the community like everybody else.”

There are some rural outliers, Van Runkle added. Some facilities in the same community may have relayed information about the vaccine differently, how they’ve gone about educating their staff and the level of effort they’ve put into it, and that led to a difference in staff vaccination.

In some cases, peer pressure and constant communication between rural staff helped get more workers vaccinated that may have been on the fence, Van Runkle said.

Direct care workers in the community “don’t check their opinions at the door,” he said, regardless of where they work.

“It also varies with who your staff are, and what their reasons are for not getting vaccinated; there’s a lot to it. Overriding factors set the limits on how far you can get. It’s the culture of the community,” Van Runkle noted.

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